Bajaj Allianz General Insurance Company Limited.

Regd. & Head Office : GE Plaza, Airport Road, Yerawada, Pune 411 006
Email id:-customercare@bajajallianz.co.in
Toll free no:1800-209-5858
020-30305858

(To be filled in block letters)

CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT PART A
TO BE FILLED IN BY THE INSURED
The issue of this form is not to be taken as an admission of liability

DETAILS OF PRIMARY INSURED

a) Policy No:

b) Sl. No/Certificate No:

c) Company TPA ID No:

d) Customer ID:

e) Company Name:__________________________________________________________f) Employee No:___________________________

SECTION A

g) Name:
h) Address:

City:

State:

Pin Code:

Phone No:

Email ID:__________________________________________________________

DETAILS OF INSURANCE HISTORY

a) Currently covered by any other Mediclaim / Health Insurance

Yes

No

b) date of commencement of first insurance without break

Policy No:

Sum Insured (Rs.):

d) Have you been hospitalized in the last four years since inception of the contract?

Yes

No

Date: D D M M

Y Y Y Y

SECTION B

c) If yes, company name:

Diagnosis
e) Previously covered by any other Mediclaim / Health Insurance:

Yes

No

f) If yes, Company Name

DETAILS OF INSURED PERSON HOSPITALIZED

a) Name of the Patient: _______________________________________________________________________________________________
b) Health ID card no of the Patient:______________________________________________________________________________________
c) Gender: Male

Female

d) Age: years

g) Occupation: Service

Spouse

Self Employed

Child

Homemaker

Father

Mother

Other

(Please Specify)

Student

Retired

Other

(Please Specify)

Y Y Y Y

h) Address (if different from above) _____________________________________________________________________________________

City:

State:

I) Phone No:

SECTION C

f) Relationship of Primary insured: Self

e) Date of Birth D D M M

months

Pin Code:

J) Email ID: ________________________________________________________

DETAILS OF HOSPITALIZATION
a) Name of Hospital where Admitted: ____________________________________________________________________________________
b) Room Category occupied: Day Care
Illness

Twin sharing

Maternity

d) Date of Injury/Date Disease first detected/Date of Delivery: D D M M

e) Date of admission D D M M

3 or more beds per room

Y Y Y Y

Y Y Y Y f) Time: H H : M M g) Date of Discharge D D M M Y Y Y Y h)Time: H H M M

I) Name of treating doctor_____________________________________Diagnosis________________________________________________

j) If injury give cause: Self
i) If Medico legal: Yes

inflicted

Road Traffic Accident

No

iii) MLC report and Police FIR attached: Yes

Substance Abuse /Alcohol Consumption

ii) Reported to police: Yes

No

j) System of Medicine

No

SECTION D

c) Hospitalisation due to: Injury

Single occupancy

DETAILS OF CLAIM
a) Details of the treatment expenses claimed
Rs.

ii. Hospitalisation Expenses

Rs.

iii. Post-Hospitalisation Expenses:

Rs.

iv. Health checkup cost

Rs.

v. Ambulance Charges:

Rs.

vi. Others (code)

Rs.

Total

Rs.

viii. Post Hospitalisation period:

days

vii. Pre-Hospitalisation period:

days

b) Claim for Domiciliary Hospitalisation: Yes

No

SECTION E

I. Pre-Hospitalisation Expenses:

(If yes, provide details in annexure)

c) Details of Lump sum / cash benefit claimed:

i. Hospital Daily Cash

Rs.

ii. Surgical Cash

Rs.

iii. Critical illness Benefit

Rs.

iv. Convalescence

Rs.

v. Pre/Post hospitalisation

Rs.

vi. Others

Rs.

Total

Rs.

lump sum benefit

Claim Documents Submitted Check List
Claim Form Duly Signed

Copy of claim intimation if any

Original Hospital Main Bill

Original Hospital Breakup Bill

Original Hospital Bill Payment Receipt

Original Hospital Discharge SummaryPharmacy Bill

Operation Theater Notes

ECG

Original Doctor's Prescriptions

Original Doctors request for investigation reports (including CT/MRI/USG/HPE)

Others

Cancelled blank cheque leaf with payee name printed. If name of the payee is not printed on the cheque leaf please attach copy of the first
page of the bank passbook.

DETAILS OF BILLS ENCLOSED

Bill No
D
D
D
D
D
D
D
D
D
D

D
D
D
D
D
D
D
D
D
D

Date
M M
M M
M M
M M
M M
M M
M M
M M
M M
M M

Issued by
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

Towards
Hospitalisation Main Bill
Pre-Hospitalisation Bills:__Nos
Post-Hospitalisation Bills:__Nos
Pharmacy Bills

Amount (Rs)
SECTION F

Sr.No
1
2
3
4
5
6
7
8
9
10

DETAILS OF PRIMARY INSURED'S BANK ACCOUNT

c) Bank Name :_____________________________________________________________________________________________________

SECTION G

a) Name of the Account Holder ( As per Bank Account):______________________________________________________________________

b) Account no ( As appearing in the cheque book):

d) Branch Name & Address:___________________________________________________________________________________________:

e) Account Type : Saving

Current

Cash Credit

f) MICR No.

g)IFSC Code:

h) PAN:

i) Cheque / DD Payable Details:

I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false
or untrue statement, suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right to claim
reimbursement shall be forfeited. I also consent & authorize Bajaj Allianz General Insurance Company Limited, to seek necessary medical
information / documents from any hospital / Medical Practitioner who ha s attended on the person against whom this claim is made. I hereby
declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the
pre/post-hospitalization claim, if any.

Date: D D M M

Y Y Y Y

Place:

Signature of the Insured

SECTION H

DECLARATION